Evidence-based Implant Treatment Planning and Clinical Protocols E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 1217

Veröffentlichungsjahr: 2016

Beschreibung

Evidence-based Implant Treatment Planning and Clinical Protocols provides a systematic approach to making treatment decisions and performing restorative procedures.  

• Offers a clinically relevant resource grounded in the latest research
• Applies an evidence-based approach to all aspects of implant dentistry, including maxillofacial prosthodontics, from planning to surgery and restoration
• Describes procedures in detail with accompanying images
• Covers all stages of treatment, from planning to execution
• Includes access to a companion website with video clips demonstrating procedures and the figures from the book in PowerPoint

Leseprobe

Table of Contents

Cover

Title Page

Contributors

Foreword

Prologue

References

Acknowledgments

About the Companion Website

CHAPTER 1: The State of the Evidence in Implant Prosthodontics

Introduction

Hierarchy of evidence

Bias

Statistics

Evaluation

Conclusion

References

CHAPTER 2: Systemic Factors Influencing Dental Implant Therapy

Immunocompromised patients

Uncontrolled diabetes

Intravenous bisphosphonates

Bleeding disorders

Recent myocardial infarction/stroke

Active treatment of malignancy

Alcohol/drug abuse

Neuropsychiatric/neuromuscular illness

Osteoporosis

Smoking

Chronic periodontitis

Autoimmune disease

Lack of surgical experience

Temporary contraindications

Summary

References

CHAPTER 3: Maintenance Considerations in Treatment Planning Implant Restorations

General considerations

Purpose, outline, and definition of terms

Clinician decisions influencing maintenance programs

Development of a patient‐specific maintenance program based on the risk factor checklist

Conclusions

References

CHAPTER 4: Three‐Dimensional Radiographic Imaging for Implant Positioning

Introduction

Three‐dimensional radiographic imaging

The issue of radiation

Levels of adjunct use of CBCT in implant dentistry

Comparative accuracy of guided surgery with different approaches

Complications

Operator sensitivity/learning curve influence

Post‐surgical evaluation of implant positions

Conclusion

References

CHAPTER 5: Decision Making in Bone Augmentation to Optimize Dental Implant Therapy

GBR techniques for horizontal and vertical augmentation

Maxillary sinus grafts

Summary

References

CHAPTER 6: Immediate Implant Placement and Provisionalization of Maxillary Anterior Single Implants

Introduction

Diagnosis and treatment planning

Clinical procedure

The challenge and potential solution of maintaining the inter‐implant papilla when replacing a tooth adjacent to an implant

Conclusions

References

CHAPTER 7: Surgical Complications in Implant Placement

Complications during execution

Errant implant position

Loss of integration/implant loosening

Errors in positioning

Patient compliance

Conclusion

References

CHAPTER 8: Failure in Osseointegration

Introduction

Patient factors

Implant factors

Clinician factors

Summary

References

CHAPTER 9: Implant Restoration of the Partially Edentulous Patient

Local factors influencing implant therapy

Indications for endodontic versus implant therapy

Indications for tooth‐supported fixed dental prostheses versus single implant crowns

Indications for implant‐fixed dental prostheses and cantilevered fixed dental prostheses

Indications for splinting multiple implants

Indications for the selection of short implants

Narrow‐diameter implants

Combined tooth‐ and implant‐supported fixed dental prostheses

Screw‐ versus cement‐retained implant restorations

Immediate loading and immediate implant placement protocols

Summary

References

CHAPTER 10: Prosthodontic Considerations in the Implant Restoration of the Esthetic Zone

Examination and site analysis

Diagnostic wax‐up, radiographic guide fabrication, and three‐dimensional imaging/virtual planning

Planning the implant position

Timing of implant placement

Measures to evaluate esthetics around dental implants in the esthetic zone

Interim restorations

Definitive restoration

Maintenance and long‐term complications

Summary

References

CHAPTER 11: Ceramic Materials in Implant Dentistry

Introduction

Materials

Abutments

Single‐unit crowns and fixed dental prostheses

Summary

References

CHAPTER 12: Cement‐Retained Implant Restorations: Problems and Solutions

Cemented restorations and issues related specifically to dental implants

Cement interactions: specific issues with implants

Luting material selection

Implant restorative cementation: developing clinical protocols

Conclusion

References

CHAPTER 13: Implant Restoration of the Growing Patient

Steps to consider in the rehabilitation of the young adult patient

Conclusions

References

CHAPTER 14: Occlusion: The Role in Implant Prosthodontics

Introduction

Occlusal considerations for implant‐borne restorations

Occlusal schemes

Summary

References

CHAPTER 15: Evolving Technologies in Implant Prosthodontics

The flow of patient data in digital implant prosthodontics (the language of digital prosthodontics)

Technologies for implant diagnosis and treatment planning

Technologies for implant placement

Technologies for implant interim prostheses

Technologies for definitive impressions

Technologies for jaw‐relation records

Technologies used in the fabrication of prostheses

Technologies for implant prosthesis delivery

Technologies for implant prosthodontic patient maintenance

Evolving technologies in implant maxillofacial prosthodontics

Future trends in implant prosthodontics

Summary

References

CHAPTER 16: Implant Dentistry

Education

Economic burden

New technologies

Marketing

Assumptions

Periodontal compromise

Future trends

Summary

References

CHAPTER 17: Implant Restoration of the Maxillary Edentulous Patient

Morphology of the edentulous maxilla

Diagnostic phase

Radiologic diagnosis and treatment planning

Restoration design options and implant numbers

Maintenance for fixed and removable restorations

Patient factors and patient‐reported outcome measurements

Summary

References

CHAPTER 18: Implant Restoration of the Mandibular Edentulous Patient

Incidence of edentulism and demographic trends on implant treatment acceptance

Systemic factors

Local factors

Patient‐mediated factors

The implant overdenture versus a conventional denture

Number of implants, anchorage system, and maintenance of the implant overdenture

Immediate‐load protocols

Implant fixed complete dentures

Fixed dental prostheses

Summary

References

CHAPTER 19: Material Considerations in the Fabrication of Prostheses for Completely Edentulous Patients

Origin of material selection for implant prostheses

Initial evaluation and treatment planning

Basic material properties

Basic screw joint mechanics

Force transfer and biomechanics

Prosthesis design

Proposed design algorithm

Material choices for prosthetics

Repair techniques

Summary

References

CHAPTER 20: Digital Alternatives in the Implant Restoration of the Edentulous Patient

Introduction

Applications of digital complete dentures with implants

Digital impressions for edentulous arches

Digital options for substuctures and monolithic framework prostheses

Conclusion

References

CHAPTER 21: Restoration of Acquired Oral Defects with Osseointegrated Implants

Introduction

Implant‐retained prostheses for acquired hard and soft palate defects

Restoration of tongue–mandible defects with osseointegrated implants

Implants in patients treated with radiation and chemoradiation

CHAPTER 22: Implant‐Retained Restoration of the Craniofacial Patient

Surgical phase

Nasal prostheses

Implant‐retained auricular prostheses

Implant‐retained orbital prostheses

Midfacial prostheses

Related advances in technology for cranionfacial implant‐retained restorations

Summary

Postscript

References

CHAPTER 23: Peri‐Implant Diseases

Introduction

Peri‐implant diseases

History

Biofilm

Peri‐implant mucositis (PIM) and peri‐implantitis (PI)

Future directions in peri‐implant disease research

Treatment

Future directions

Conclusion

References

Epilogue

Index

End User License Agreement

List of Tables

Chapter 02

Table 2.1 ASA classification system for assessing relative risk for surgical procedures.

Table 2.2 Glycated hemoglobin (HbA1c) targets.

Table 2.3 Conversion of glycated haemoglobin (HbA1c) to blood glucose level.

Table 2.4 Relative potency of nitrogen‐containing bisphosphonates.

21

Chapter 03

Table 3.1 Risk factors for biologic and mechanical complications (CAMBRA, caries management by risk assessment; CHX, chlorhexidine; OHI, oral hygiene instruction; SSRIs, selective serotonin reuptake inhibitors).

Table 3.2 Clinical risk factors determined after patient has implants (CHX, chlorhexidine).

Chapter 04

Table 4.1 Effective radiation dosages (in micro‐sieverts) from different sources.

1,2,5

Table 4.2 Radiation dosage for different CBCT machines and different field of view (FOV).

Table 4.3 Advantages and disadvantages of computer image guided surgery in implant dentistry.

Chapter 07

Table 7.1 Classifications of nerve injuries.

Chapter 08

Table 8.1 Osseoseparation staging system.

Chapter 10

Table 10.1 Description of indices for assessment of single‐tooth implant esthetics.

Chapter 12

Table 12.1 Cement types identified in 19 soft tissue biopsy samples of failed, removed implants.

Table 12.2 Some considerations for material selection specific to teeth and implants for cemented restorations.

36

Chapter 16

Table 16.1 Checklist for prognostic classification of complete edentulism.

Chapter 17

Table 17.1 Diagnostic form for the edentulous maxilla (distribution of crosses indicate recommended prosthesis design).

Chapter 19

Table 19.1 Comparison of different restorative material physical properties (PMMA, polymethyl methacrylate).

Table 19.2 Comparison of physical properties of various grades of titanium. Data from American Society for Testing and Materials (ASTM international Standards).

Table 19.3 Alloy selection for metal–ceramic prostheses.

Chapter 22

Table 22.1 Criteria for success (Pt, patient; QoL, quality of life; Rxn, reaction).

Table 22.2 Catergories I–V (Pt, patient; Rxn, reaction).

Chapter 23

Table 23.1 Natural tooth vs. implant gingival complex and attachment mechanism.

Table 23.2 Diagnostic checklist for peri‐implant disease.

List of Illustrations

Chapter 01

Figure 1.1 Hierarchy of evidence.

Chapter 02

Figure 2.1 Osteonecrosis of the jaw.

Figure 2.2 Implant perforation of lingual plate.

Chapter 03

Figure 3.1 In the patient who presents with periodontal disease and poor compliance, the increased risks of implant loss need to be reviewed, and a maintenance program agreed to.

1,4,11

Figure 3.2 At the treatment planning appointment, especially in patients with poor compliance, it is often helpful to show clinical examples of how bone can be lost quickly and asymptomatically around a dental implant. Guiding the patient to articulate a desire for compliance early in treatment can improve outcomes. This is called motivational interviewing and has resulted in improved outcomes in medicine by improving compliance.

12

Figure 3.3

(a–c)

Maintenance needs are expected with implant restorations. In a recent systematic review of technical and biologic complications over a 10‐year period, only 8.6% of prostheses did not have complications.

52

Both the patient and clinician need to prepare for this potential.

52

The most common biologic complications were hypertrophy or hyperplasia of tissue and inflammation under the prosthesis. The most common technical complications included chipping/fracture of veneering material, screw loosening, screw fracture, fabrication of new opposing prostheses, replacement resin teeth, wear of resin teeth, framework fracture, and patient dissatisfaction.

52

Figure 3.4

(a–c)

For this patient ready to receive a maxillary and mandibular implant‐supported fixed prostheses fabricated from zirconia, access for cleaning was established early with re‐contouring of the provisional until the patient could maintain tissue health. Since the most common biologic complications are gingival hypertrophy and inflammation under the prosthesis, it is important the patient be able to maintain peri‐implant tissue health before delivery of the definitive restoration.

52

Figure 3.5 Lack of attached tissue is a risk factor around implants and encourages food impaction.

1

Note the high muscle attachment proximal to the cuspid, which creates moving tissue not just movable tissue, potentiating patient discomfort. In such a situation, a connective tissue graft is recommended, ideally during the time the patient is wearing a provisional restoration, before the definitive restoration.

63

Figure 3.6

(a)

Example of extensive prosthesis coverage of gingiva and marginal tissues of implants.

(b)

The resulting marginal irritation should be avoided if possible. The patient’s ability to maintain the tissue should be evaluated in the provisional. If the restoration contours cannot be modified, frequent recalls, use of a water flosser, floss threaders, and triclosan‐containing toothpaste should be considered.

(c, d)

One modification that facilitates hygiene access is the contouring of gingival grooves in the prosthetic flange.

Figure 3.7

(a)

In a patient with poor oral hygiene, the patient needs to understand that without appropriate maintenance they are much more likely to have maintenance complications that can create esthetic concerns and result in the loss of implants.

(b)

This patient responded to 2‐month recalls with reinforcement, triclosan‐containing gum, and use of brushes.

47,48

Figure 3.8 Ideally a maintenance plan will be developed while treatment planning. When a patient is referred who has existing implants with bone loss, a more aggressive maintenance program should be considered.

Figure 3.9 This patient has mucositis defined as bleeding on light probing. The abutment connections were open leaving a nidus for plaque accumulation. Additionally, the patient wore their prosthesis at night and had difficulty cleaning. Placing the patient on frequent recalls helped improve tissue health.

Figure 3.10 There is an increased potential for caries on teeth adjacent to implant restorations. The maintenance plan needs to account for this. Often teeth adjacent to implant restorations have recession and are susceptible to root caries. A high‐fluoride toothpaste for at‐home maintenance and fluoride varnish for in‐office recall appointments should be considered.

60

Figure 3.11 (a–d) This implant‐supported fixed prosthesis was completed in zirconia. The prosthesis has minimal tissue coverage and was evaluated in the provisional for patient access for cleaning, speech, and comfort. Extensive tissue coverage can be avoided through careful patient selection.

Chapter 04

Figure 4.1 Radiographic template used for identifying the desired position of the restored teeth, here marked by barium sulfate.

Figure 4.2 CBCT virtual 3D planning tool for implant positioning.

(a)

Mandibular arch generated from intraoral scan.

(b)

Sagittal position of implant in #19 site.

(c)

Sagittal view of implant in #19 site with superimposition of radiographic template.

(d)

Occlusal view of implant in #19 site with superimposition of radiographic template.

Figure 4.3 Different approaches to guide fabrication showing soft‐tissue‐supported guide on the left with fixation pins, and tooth‐supported guide on the right.

Chapter 05

Figure 5.1 Preoperative view of a “knife‐edge” ridge depicting a horizontal bone defect.

Figure 5.2 Typical vertical ridge defect in an interdental situation.

Figure 5.3 Preoperative view of a patient presenting with a horizontal and vertical defect.

Figure 5.4 The divergent vertical releasing incision is made three teeth away from the defect in order to help mobilize the flap.

Figure 5.5 Incision made lateral to the retromolar area to obtain access to the donor autogenous bone site.

Figure 5.6 Trephine burs used to harvest autogenous bone cores.

Figure 5.7 Example of multiple decortication holes to help vascularize the bone graft.

Figure 5.8 Trimming the nonresorbable membrane to adequately contain the graft.

Figure 5.9 The nonresorbable membrane is attached to the palatal bone and the graft material is incorporated into the area.

Figure 5.10 Notice the multiple titanium tacks fixing the nonresorbable membrane.

Figure 5.11 Horizontal mattress sutures approximating the flaps for the first suture layer.

Figure 5.12 Multiple single interrupted sutures for complete closure of the entire area.

Figure 5.13 Postoperative view of the grafted area 2 months after surgery.

Figure 5.14 Occlusal view depicting the healthy appearance of the augmented site after 2 months.

Figure 5.15 Histology of the mixture of autogenous bone and ABBM, demonstrating that the ABBM is connected by a dense network of newly formed bone.

Figure 5.16 A clinical example of an horizontally augmented ridge before implant placement.

Figure 5.17 Implants placed during the second stage of treatment of the horizontally regenerated ridge.

Figure 5.18 A clinical example depicting the presence of a nonresorbable membrane before its removal after 6 months of healing.

Figure 5.19 Notice the regenerated bone after removal of the e‐PTFE membrane.

Figure 5.20 The clinical picture demonstrates the required distance between the edges of the membrane and adjacent teeth and mental nerve.

Figure 5.21 Typical appearance of a successful vertically regenerated ridge.

Figure 5.22 Postoperative radiograph of a vertical augmentation procedure clearly showing the titanium strips embedded in the nonresorbable membrane.

Figure 5.23 Postoperative radiograph of the placement of three implants in the grafted site. Notice that the membrane has been removed.

Figure 5.24 Postoperative radiographic view of the three endosseous implants recently uncovered after 4 months of healing.

Figure 5.25 Radiograph taken 7 years post loading, depicting adequate marginal bone levels.

Figure 5.26 Cone beam CT preoperative image depicting a pneumatized maxillary sinus.

Figure 5.27 CBCT images of a completely (left) pneumatized sinus and a partially (right) pneumatized sinus.

Figure 5.28 Rotary osteotomy instrumentation for the lateral approach to the maxillary sinus cavity.

Figure 5.29 Piezosurgery instrumentation depicting the initial separation of the membrane before the use of sinus curettes.

Figure 5.30 Notice the internal irrigation capability of a DASK drill for the lateral approach to the maxillary sinus cavity.

Figure 5.31 Clinical photograph of the DASK osteotomy instrumentation technique thinning the lateral bony aspect of the maxillary sinus cavity. Notice the blueish appearance of the bone as the drilling action approximates the maxillary sinus membrane.

Figure 5.32 Maxillary sinus curettes in the initial stages of the maxillary sinus elevation.

Figure 5.33 Radiograph taken 8 years after a simultaneous maxillary sinus graft procedure and vertical ridge augmentation. Notice the relatively radiopaque crest of the ridge and maxillary sinus cavity.

Chapter 06

Figure 6.1 Gingival level of the failing tooth (#9) should be (1) the same as (or more coronal than) that of the contralateral tooth and (2) harmonious with the adjacent dentition, as some gingival recession can be expected after the procedure.

Figure 6.2 Osseous–gingival tissue relationship can be evaluated by bone sounding and should measure 3 mm on the facial aspect of the failing tooth and 4.5 mm on the proximal aspect of adjacent teeth.

Figure 6.3 Sagittal root position classification. Class I: the root is positioned against the labial cortical plate. Class II: the root is centered in the middle of the alveolar housing without engaging either labial or palatal cortical plates at the apical one‐third of the root. Class III: the root is positioned against the palatal cortical plate. Class IV: at least two‐thirds of the root is engaging both labial and palatal cortical plates.

Figure 6.4 Periapical radiograph of the failing tooth.

Figure 6.5 Facial bone defect classification. V‐shaped defect: isolated only to the mid‐facial portion of the facial bony plate. U‐shaped defect: extends to the mesial and/or distal aspect of the failing tooth. UU‐shaped defect: extends to the mesial and distal aspects of the immediately adjacent teeth.

Figure 6.6 The implant should be placed at the center of the predetermined mesiodistal width of the final restoration with a minimal distance of 2 mm from the adjacent tooth.

Figure 6.7 Bone graft material is placed into the gaps between the implant and the bony socket to maintain facial osseous contour.

Figure 6.8 Subepithelial connective tissue graft (SCTG) can be placed simultaneously with cementation of the provisional restoration.

Figure 6.9 Periapical radiograph of IIPP of #9.

Figure 6.10 Clinical image of provisional restoration after 4 months of healing.

Figure 6.11 Customized zirconium abutment.

Figure 6.12 Cementation of an all‐ceramic definitive restoration.

Figure 6.13

(a)

Clinical and

(b)

radiographic images of the definitive restoration 4 years after surgery.

Figure 6.14

(a)

Pretreatment frontal view of failing maxillary left lateral incisor (#10).

(b)

Pretreatment periapical radiograph of #10.

Figure 6.15 Immediate implant placement after preparation of a 1.5–2 mm uniformly thick C‐shaped mesial root fragment.

Figure 6.16 Immediate implant placement at the maxillary left lateral incisor position.

Figure 6.17 The screw‐retained provisional restoration was hand tightened onto the implant.

Figure 6.18 Periapical radiograph of proximal socket‐shield with immediate implant placement and provisionalization.

Figure 6.19

(a)

Definitive restoration of #10 at 4‐year follow‐up. Note the maintenance of the interproximal peri‐implant papilla.

(b)

Periapical radiograph of definitive restoration of #10 at 4 years.

Chapter 07

Figure 7.1 Assessing anesthesia.

Figure 7.2 Kit for evaluating nerve injuries.

Figure 7.3 Distance from anterior loop of the inferior alveolar nerve, measuring for safe distance from the mental foramen.

Figure 7.4 Drugs for medical management of nerve injuries.

Figure 7.5 Intraoral presentation of ranula.

Figure 7.6 Extraoral presentation of plunging ranula.

Figure 7.7 Zygomatic implant (left posterior site).

Figure 7.8 Zygoma implant traversing the maxillary sinus and engaging the zygomatic process.

Figure 7.9 Periapical radiograph demonstrating convergent root apices.

Figure 7.10 Periapical radiograph depicting adequate apical spread.

Figure 7.11 Implant displaced into the maxillary sinus.

Chapter 08

Figure 8.1 Foreign body equilibrium reaction.

Figure 8.2 The osseosufficiency triad of clinician, patient, and implant.

Chapter 09

Figure 9.1 Pyramid of success when considering critical factors in diagnosis and treatment planning of implant prostheses.

Figure 9.2 Placement of implant in horizontal plane with ≥2 mm bone facial to fixture.

Figure 9.3 Placement of implant in frontal plane 2–3 mm apical to the adjacent teeth cementoenamel junction.

Figure 9.4

(a)

Class II, division 2 jaw relation pre‐empting replacement of decoronated roots with a screw‐retained implant fixed dental prosthesis due to the lack of sufficient space for the screw‐access housing.

(b)

Supraeruption of mandibular incisors encroaching on restorative space for implant prosthesis.

(c)

Orthodontic intrusion of mandibular incisors to accommodate maxillary anterior restorative requirements and harmonious crown morphologies.

Figure 9.5

(a, b)

Minimum of 5 mm interocclusal space is required for screw‐retained restorations.

(c)

A minimum of 7 mm of interocclusal space is required for a cement‐retained crown allowing at least 5 mm for abutment height.

(d)

Canine guidance or group function developed when restoring a posterior implant crown.

(e)

Implant not placed orthogonally with occlusal plane obviating the use of screw‐retained design. However, restricted interarch space has compromised retention of a cement‐retained prosthesis. Auxiliary retention using a lateral screw would be appropriate.

Figure 9.6

(a)

Measurement of vertical space to assess interarch accommodation for screw‐ or cement‐retained restorations. Despite the 5 mm allowance for a screw‐retained restoration in this scenario, equilibration or restoration of antagonist teeth would be necessary to eliminate excursive interferences.

(b)

Supraeruption of maxillary second bicuspid and first molar influencing design of antagonist crown height and occlusal scheme in lateral excursions.

(c)

Use of buccal and palatal temporary anchorage devices (TADs) for intrusion with expected movement of 0.5–1 mm per month for adults.

Figure 9.7

(a)

Thick gingival biotype, square tooth morphology, wide band of attached tissue, short papillae.

(b)

Thin gingival biotype, trigonal tooth morphology, narrow band of attached tissue, long papillae.

Figure 9.8 Extraction of central incisor on thin biotype without ridge‐preservation procedure.

Figure 9.9

(a)

Maxillary left central incisor is unrestorable.

(b)

Periapical radiograph disclosing internal and external resorption.

(c)

Subepithelial connective tissue graft in conjunction with implant placement.

(d)

Palatal donor site for graft.

(e)

Resin‐bonded bridge (facial view).

(f)

Resin‐bonded bridge reinforced with orthodontic braided wire (palatal view).

(g)

Periapical radiograph of implant while integrating.

(h)

Patient with full smile with restoration in place.

Figure 9.10

(a)

Individual porcelain fused to metal crowns on sites #7, 8, 9, 10 implants.

(b)

Platform‐switched abutment design.

Figure 9.11 Approximately 10% reduced chance of complete healing after primary endodontic treatment for #8 compared to #9 because of apical radiolucency.

Figure 9.12

(a)

Accuitomo scan of calcified canal of #10.

(b)

Gates‐Glidden drill (Dentsply Tulsa Dental Specialties, Tulsa OK) accessing calcified blockage.

(c)

Completed obturation of #10.

Figure 9.13 Interproximal bone preserved with natural tooth (#5) proximal to implant restoration, placing premium on retreatment of this tooth.

Figure 9.14 Three‐unit fixed dental prosthesis replacing #8.

Figure 9.15

(a)

Healing abutment in #8 site.

(b)

Single implant crown replacing #8.

Figure 9.16

(a)

Zirconia abutment affixed to implant in #8 site.

(b)

All‐ceramic crown restoring #8.

(c)

Periapical radiograph.

Figure 9.17

(a)

Titanium abutments to support a fixed dental prosthesis.

(b)

Porcelain‐fused‐to‐metal implant fixed dental prosthesis.

Figure 9.18

(a)

Titanium abutments supporting posterior implant reconstruction.

(b)

Periapical radiograph of abutments affixed to implants which will support a fixed dental prosthesis.

(c)

Periapical radiograph of abutments affixed to implants which will support individual crowns.

(d)

Definitive restorations on master cast.

Figure 9.19

(a)

Space analysis considering minimum mesiodistal requirements of inter‐implant and implant–tooth distances for housing three implants. A three‐unit fixed dental prosthesis supported by two implants is a viable alternative when space is at a premium.

(b)

One implant per crown, screw‐retained in a three‐unit splint.

(c)

Periapical radiograph of three implants. If one fails, the prosthesis can be converted into a ready‐made fixed dental prosthesis.

Figure 9.20 CBCT software planning for tilted implant fixed dental prosthesis design to avoid sinus grafting.

Figure 9.21 Implant cantilevered fixed dental prosthesis with marginal bone maintenance on implant proximal to cantilever.

Figure 9.22

(a)

Sufficient abutment length to retain a cantilever prosthesis.

(b)

Definitive three‐unit porcelain‐fused‐to‐metal cantilever prosthesis.

(c)

Periapical radiograph of cantilever prosthesis in

(b)

.

Figure 9.23

(a)

Individual implant‐supported crowns.

(b)

Periapical radiograph of unsplinted crowns.

Figure 9.24 Splinted crowns with distal units approaching effective crown lengths of 15 mm.

Figure 9.25 Opened interproximal contact between implant crowns due to continued craniofacial growth over 20 years of service.

Figure 9.26

(a)

Natural tooth and implant abutment supporting a mixed fixed dental prosthesis.

(b)

Framework design with nonrigid connector which has been linked to a 5‐year, 5.2% incidence of intrusion of the natural tooth abutment.

Figure 9.27

(a)

Three‐unit fixed dental prosthesis with screw‐retained design on first molar and cement‐retained design on first bicuspid.

(b)

Graphic depicting the “hybrid” design in Figure 9.26.

Figure 9.28

(a)

Preoperative occlusal view of maxillary partially edentulous arch.

(b)

Frontal view of abutments for cement‐retained cantilevered implant‐fixed dental prosthesis design.

(c)

Occlusal view of abutments for cantilevered implant‐fixed dental prosthesis with compromised retention due to both U‐shaped arch and short abutments.

(d)

Frontal view of metal framework for cantilevered implant fixed dental prosthesis which demonstrated an anterior–posterior movement on try‐in.

Figure 9.29

(a)

Angulated Screw Channel design with Nobel Active implant system allowing offset of up to 25° implant axis to cingulum for a screw‐retained zirconia crown.

Figure 9.30

(a)

Conometric design using frictional retention instead of cement for three‐unit fixed dental prosthesis.

(b)

Intaglio of fixed dental prosthesis restoring

(a)

.

(c)

Definitive three‐unit fixed dental prosthesis.

(d)

Periapical radiograph of fixed dental prosthesis in

c

.

Figure 9.31

(a)

Extraction of root remnant #10 and immediate placement of implant.

(b)

Immediate provisional crown placement #10.

Figure 9.32

(a)

Advanced periodontal attachment loss on #9.

(b)

Periapical radiograph.

(c)

Orthodontic forced extraction to level the crestal bone before implant placement.

(d)

Extraction of #9.

(e)

Definitive implant crown in place.

(f)

Periapical radiograph of

(e)

.

Figure 9.33 Spectrum of attachment loss (type I–V), all of which can capitalize on forced extraction to improve the bony housing for prospective implant placement as described in Amato

et al

. 2012.

137

Chapter 10

Figure 10.1

(a)

Radiographic guide fabricated using radiopaque teeth tried intraorally prior to obtaining CBCT. GC resin occlusal jig in place to allow separation of teeth and stabilize the patient during the process.

(b)

Sagittal section through site #9 shows the exact relation of the proposed final restoration position to the available bone bed demonstrating availability of bone for proper 3‐D positioning of the fixture.

Figure 10.2

(a)

Diagnostic wax‐up for the proposed definitive restorations on maxillary left central and lateral incisors.

(b)

Radiographic guide fabricated using a vacuum template with lead foils centered on each tooth tried intraorally, demonstrating deficiency in facial bone in relation to the proposed definitive restoration position.

(c)

Sagittal section through the CBCT volume showing deficiency in facial bone that was noticed clinically in a quantifiable manner. In such a case, augmentation would be considered based on these findings.

Figure 10.3

(a)

Screen shot of the 3D view for virtual implant planning using Simplant Software. This is utilized to plan for implants at sites #9, 11, and 13.

(b)

Sagittal section that shows the long axis of implant planned at site #11. Planning was executed to allow for a screw‐retained prosthesis.

(c)

Occlusal view of the teeth‐supported CAD/CAM guide in place.

Figure 10.4

(a)

Occlusal view of implant placed at site #8 demonstrating its facial and superficial misplacement. This creates a restorative challenge for providing a proper emergence profile and symmetrical midfacial gingival margin.

(b)

Facial view of zirconia abutment used to restore implant at site #8. Selection of zirconia was based on the patient’s thin tissue biotype.

(c)

Facial view of definitive implant restoration. Asymmetrical gingival zenith has resulted from inadequate implant placement.

Figure 10.5

(a)

Facial view of implant crown at site #7 demonstrating deficient papillae on both the mesial and distal aspects.

(b)

Periapical radiograph at implant #7 demonstrating good marginal peri‐implant bone levels but reduced levels on adjacent teeth. Soft tissue levels around single‐tooth dental implants are affected by bone levels on adjacent teeth.

Figure 10.6

(a)

Missing maxillary anterior teeth and deficient hard and soft tissues as a result of trauma; vertical augmentation would not be predictable.

(b)

The definitive abutments with gold hue in place.

(c)

The use of pink ceramics was a necessity to compensate for the lost tissues and provide an optimum esthetic result.

Figure 10.7

(a)

A three‐unit FDP adjacent to a natural tooth that needs a crown restoration. Custom abutments with gold hue are used to optimize esthetics.

(b)

Long proximal contacts were created to camouflage the short interdental papilla.

Figure 10.8 Lateral view of a full‐arch monolithic zirconia prosthesis with artificial gingiva showing flat pontic design to facilitate hygiene.

Figure 10.9

(a)

The use of an acrylic partial denture as an interim prosthesis.

(b)

Essix retainer used an interim prosthesis by filling the area of missing teeth with Bis‐Acryl material.

(c, d)

Bonding an interim restoration to adjacent teeth utilizing an index fabricated from the diagnostic wax‐up.

(e–g)

The use of a screw‐retained interim crown.

Figure 10.10

(a)

Occlusal view of the soft tissue contouring accomplished by use of a properly designed interim implant‐supported prosthesis.

(b)

Duplication of soft tissue contours into the design of the definitive implant prosthesis.

Figure 10.11

(a)

Facial view of gold‐hue custom Atlantis abutments used to restore implants at sites #7 and 10.

(b)

Facial view of definitive implant crowns fabricated using lithium‐disilicate (E‐max press) at implants #7 and 10.

Figure 10.12

(a)

Facial view demonstrating discrepancy of the incisal edges of implant‐supported prostheses at implants #9 and 10 with natural teeth (infra‐occlusion). This creates a significant esthetic complication for patients in the anterior zone in the long‐term.

(b)

Periapical radiograph for implants at sites #9 and 10 with splinted prostheses demonstrating some bone loss.

Chapter 11

Figure 11.1

(a)

IPS e.max pressable ingot.

(b)

IPS e.max CAD block.

Figure 11.2 Cross‐section of layered zirconia crown depicting zirconia and veneering porcelain.

Figure 11.3

(a)

Layered zirconia restoration with veneering ceramic fractured.

Figure 11.4

(a)

Zirconia CAD/CAM abutment in place.

(b)

Gold hue abutment in place.

Figure 11.5

(a)

Colorized zirconia abutment.

(b)

Zirconia abutment in place.

(c)

Definitive lithium disilicate crown in place.

Figure 11.6 Grayish coloration in the gingiva from a titanium healing abutment.

Figure 11.7 One‐piece zirconia abutment.

Figure 11.8 Two‐piece zirconia abutment with titanium base.

Figure 11.9 Fractured one‐piece zirconia abutment.

Figure 11.10

(a)

Opaqued titanium abutment.

(b)

Opaqued titanium abutment in place.

(c)

Lithium disilicate crown in place.

Figure 11.11 Lithium disilicate crown #7 on zirconia abutment.

Figure 11.12 Zirconia crown on gold hue abutment in #7 position.

Figure 11.13

(a)

Zirconia two‐piece abutment #5 (occlusal view).

(b)

Zirconia abutment #5 (facial view).

(c)

Monolithic lithium disilicate crown in place (#5).

Figure 11.14

(a)

Gold hue abutment #2.

(b)

Monolithic zirconia crown #2 in place.

Figure 11.15 Cerasmart milling block.

Figure 11.16 Partially veneered zirconia fixed dental prosthesis.

Chapter 12

Figure 12.1 Biological attachment of a natural tooth. Connective tissue fibers insert into the root apical to the junctional epithelium.

Figure 12.2 Biological attachment to a dental implant. There is no insertion of connective tissue fibers into the implant surface.

Figure 12.3 Example of Implant site with residual excess cement and associated peri‐implantitis. Note the generalized “crater” pattern of bone loss relates to the character of the biological attachment.

Figure 12.4 Series of photographs indicating the bone loss associated with an implant and residual excess cement and deep soft tissue cement margin.

(a)

Presenting with inflammation of the soft tissues.

(b)

Full‐thickness flap elevation – granulation tissue and cement evident.

(c)

Cement removed from implant and tissues.

(d)

Cement remnants.

Figure 12.5 Example of test wells following 2 days of anaerobic incubation.

F. nucleatum

with four test cements, positive and negative controls are included in test. Note control wells – they contain no cement. The clear wells are the negative control (sterile).

Figure 12.6 Planktonic growth measurement on different cements by opacity test (OD 600) values.

(a)

Aggregatibacter actinomycetemcomitans – Aa

.

(b)

Fusobacterium nucleatum – Fn

.

(c)

Porphyromonas gingivalis – Pg

. FL, Fleck’s Cement; ML, Multilink Implant; PIC, Premier Implant Cement; TBNE, Temp‐Bond Non‐eugenol; TBO, TempBond Original. Positive control (media with bacteria, no cement) and negative control (sterile media) also shown.

Figure 12.7 Examples of agar plates with colony‐forming units (CFUs) obtained from cement disks sampled for

Aggregatibacter actinomycetemcomitans

biofilm growth.

(a)

No CFUs (TempBond Original).

(b)

CFUs >5000 and too numerous to count (Multilink).

Figure 12.8 Data graph on definitive cements used for implant and tooth restorations by USA dental schools. (RMGI, resin modified glass ionomer; ZOE, zinc oxide eugenol; GI, glass ionomer; ZP, zinc phosphate; PC, polycarboxylate; AU, acrylic urethane).

Figure 12.9 Scanning electron microscope image of the surface of a turned titanium alloy disk – the machined marks are visible as concentric lines. The surface shows pitting corrosion after the application of Durelon cement. This surface pitting perpetuates the corrosion over the electrochemically active heterogeneous surface.

Figure 12.10

(a)

Radiograph made after crown cementation indicates residual excess cement.

(b)

The crown has been removed along with the abutment, residual excess cement is obvious.

Figure 12.11

(a)

Radiograph indicating crater‐effect bone loss. No indication of cement.

(b)

Surgical flap exposes residual excess cement. This poorly radiopaque cement has similar radiopacity to air.

(c)

Cement remnants against periodontal probe indicating size of material removed.

Figure 12.12

(a)

Implant crown with peri‐implantitis, suppuration is seen.

(b)

Crown removed, poorly contoured.

(c)

Abutment removed with cement residue present.

(d)

Crown reseated on abutment showing deep margins and lack of control of cement.

(e)

Crown, abutment, and residual cement.

Figure 12.13 Actual examples of cement application techniques and amounts.

(a)

Overfilled beyond the margins of the crown.

(b)

Underfilled with insufficient amount of cement.

Figure 12.14 Examples of the application techniques: gross application, brush application, margin application.

Figure 12.15 Box plots of the application techniques and the quantity of cement loaded. The median, 25th and 75th percentile, as well as highest and lowest value range are shown. The horizontal line above the box plots indicates no significant differences (P>.05). The lower arrowhead and dotted line indicates “ideal” cement lute quantity given a 40 µm relief space. The upper arrow and dashed line indicate maximum intaglio cement fill (used as the control).

Figure 12.16 An implant abutment

(a)

has a similar occlusal taper to this clear plastic drinking beaker

(b)

. The beakers are designed to seat one on top of another mimicking a crown seated onto an implant abutment.

Figure 12.17

(a)

Cement (shaving foam) placed at the crown margin.

(b)

The crown seats easily with little resistance and the cement flow is toward the occlusal.

(c)

At fully seating a minimal amount of cement extrusion is noted and the lute space fill is complete.

Figure 12.18

(a)

The cement is gross applied.

(b)

A large excess is extruded through the margin.

Figure 12.19 Copy scanned and digitized abutment

(a)

and crown

(b)

virtual models for the computational fluid dynamics study.

Figure 12.20 Series of stills taken from real‐time simulations.

(a)

Crown with cement loaded at the crown margin start of process.

(b)

Crown being seated with cement flow.

(c)

Complete seating indicating flow and excess cement extrusion.

Figure 12.21 Computer simulation relating to cement application site. Cement (red) exchanged for air (blue). Both simulations have the same parameters except site of application.

(a)

Cement placed at the margin crown site.

(b)

Cement placed more occlussaly. Note how the margin fill differs and how the cement extrudes from the crown

(b)

before it fully seats.

Figure 12.22 Computer simulation with different implant abutment designs – closed off abutment, leaving the abutment screw‐access channel open, internal venting.

Figure 12.23 The velocity of cement extrusion can also be determined. This relates to the extrusion forces induced at the margin. Such information can determine if the hemidesmosomal attachment will be disrupted as the cement is forced out of the system. The different colors relate to velocity.

Figure 12.24

(a)

CAD/CAM zirconia abutment with a porcelain margin added.

(b)

Supragingival margin design, with the ability to be directly bonded to the reciprocating margin of the crown.

(c)

Bonded margin‐to‐margin crown and abutment.

Figure 12.25 Implant site.

(a)

Porcelain abutment margins may be added to mimic a restoration.

(b)

This margin is several millimeters from the gingiva, and is highly esthetic.

Figure 12.26

(a)

Supragingival margins allow barrier protectors (PTFE bib) to be used. It must be away from the implant screw and cement margin site so as not to be trapped.

(b, c)

Bib protects the soft tissues and helps maintain a dry field for bonding.

(d)

Excess cement and bib easily removed.

(e)

Final restoration.

Figure 12.27 Copy abutment technique.

(a)

Crown intaglio coated with petroleum jelly and PTFE tape.

(b)

Brush used to assist adaptation of the PTFE lining.

(c)

The PTFE well adapted to the inside of the crown.

(d)

The crown with PTFE spacer being filled with PVS material.

(e)

Base extended after abutment replica formed.

(f)

PVS abutment and base removed from crown.

(g)

Once removed the copy abutment (smaller by 50 µm in all dimensions than the intaglio of the crown) is seen next to the original abutment.

(h)

The copy PVS abutment pushed into the crown with cement being extruded extraorally.

(i)

the crown is seated with minimal clean up (note tissue blanching is from abutment).

Figure 12.28

(a)

Multi‐unit cemented prosthesis on cast.

(b)

PVS copy abutment for use prior to cementation.

Figure 12.29 Left to right: Internal vented abutment (IVA), open abutment (OA), closed abutment (CA).

Figure 12.30 Comparison of cement amount extruded/retained internally to abutment when similar amounts are used. Red arrow indicates amount of excess cement extruded out, blue column amount retained within the crown/abutment system. More excess is seen when there is no internal venting.

Figure 12.31 Cement flow pattern in abutments.

(a)

OA air entrapment.

(b)

IVA with complete fill.

Figure 12.32 Graph indicating retentive force of cemented crown according to abutment design (CA, closed abutment; OA, open abutment; IVA, internal vented abutment). Statistical analysis, *P<.001, **P<.01, ***P<.05.

Figure 12.33 Esthetic zirconia abutments with modifications from study. Left to right: open abutment (OA), closed abutment (CA), insert abutment (IA).

Figure 12.34 Graph showing effect on retention of the zirconia crown according to modification seen in Figure 12.33.

Figure 12.35 Cement fracture pattern after removal of the crown.

(a)

CA – very little cement remained.

(b)

Cement remains within the crown.

Figure 12.36 Cement fracture pattern with the zirconia OA group.

(a)

Minor amount of cement seen on abutment.

(b)

The cement failed to fill the screw‐access hole completely, an air void is noted inside the crown.

Figure 12.37 Cement fracture in IA group.

(a)

Cement internalized and filling the screw locking into the insert.

(b)

The cement fracture is very different to other groups (OA, CA).

Figure 12.38

(a)

Components of cement–screw‐retained restoration – crown with occlusal hole, abutment screw, titanium base.

(b)

Titanium base attached to implant analog on the cast.

(c)

Controlled cementation of crown to titanium base.

(d)

Cement–screw‐retained restoration delivered to implant.

Figure 12.39 Angulated Screw Channel abutment (NobelBiocare, Switzerland) is a zirconia CAD/CAM abutment: it allows angle deviations up to 25°.

Chapter 13

Figure 13.1 X‐linked hypohidriotic ectodermal dysplasia.

(a)

Intraoral appearance shows the typical oligodontia, cone‐shaped teeth, and retained primary teeth. The class III malocclusion, common in this population, is also evident in this image.

(b)

Radiographic appearance of the oligodontia.

(c)

Hyposalivation is common in this population since the salivary glands are derived in the same manner that sweat glands are formed. Use of frequent 5% NaF applications is recommended.

(d)

Provisional removable overdenture partial denture prosthesis for the maxilla.

(e)

Provisional removable partial denture for the mandible.

(f)

Prostheses in place at increased vertical dimension to match appropriate profile and need for interocclusal distance.

Figure 13.2

(a, b)

Maxillary removable partial prosthesis. Age‐appropriate sized replacement teeth used on the maxillary partial denture in a 5‐year old.

Figure 13.3 Use of TADs to assist in anchorage for orthodontic movement of the four anterior teeth that the patient formed.

Figure 13.4

(a–d)

Interim restorations are useful as an expeditious approach to esthetics and phonetics in the growing child. This patient presented with healing implants that were placed in bone grafts; therefore, an interim removable partial denture was used during the healing period.

Figure 13.5 A 35‐year‐old male with Witkop’s syndrome presents with multiple malformed permanent teeth and retained primary teeth.

(a)

Retained primary teeth in maxillary right quadrant have maintained the alveolar bone and soft tissue architecture in this area. The diastemas between the anterior teeth are created as part of the planning for ceramic veneers on these teeth. The mandibular right side has a significant facial bone atrophy in the premolar region.

(b)

Panoramic radiograph demonstrating the retained primary teeth.

(c)

Diagnostic casts showing planning for implant and veneers on the right side.

(d)

Diagnostic casts showing planning for implants and veneers on the left side.

(e, f)

Diagnostic wax‐up performed to estimate contours.

(g)

Ceramic veneers (EMax lithium disilicate etchable glass) are very useful to establish contours and esthetics when teeth are malformed. Note the design is as full a wrap‐around design as possible.

(h)

Clinical image showing change in incisal length and contours with the veneers. The veneers can be done either simultaneous with the implant restorations or the implants can be provisionalized, then the veneers placed, and then the final implant restorations made or the veneers can be completed as the implants are healing. In general, the second, three‐step approach is most predictable.

(i, j)

Custom abutments are in place and final restorations are adjusted and the occlusion evaluated.

(k, l)

Lateral views of the completed restorations.

(m, n)

Final facial view of the completed restorations.

Chapter 14

Figure 14.1 Periapical radiograph of a long‐term successful outcome from a short implant supported single crown with excessive crown–implant ratio. Notice that the veneering porcelain on the occlusal surface is well supported by the metal coping.

Figure 14.2 Panoramic radiograph of a long‐term successful outcome of a mandibular fixed prosthesis with bilateral cantilevers, supported by only three short implants. The implant length was dictated by the height of the residual mandible that was severely resorbed.

Figure 14.3 Periapical radiograph of a patient with an implant restoration splinted to natural tooth. This patient presented with pain and discomfort that was attributed to the failing natural tooth.

Figure 14.4 Periapical radiograph of patient in Figure 14.3 after removal of the restoration and extraction of the natural tooth indicates a fractured implant. This is a classic appearance of fracture of an internal‐connection implant caused by hoop stress.

Figure 14.5 Clinical presentation of a fractured implant, which supported a single crown in the maxillary left second premolar region, from a bruxism patient.

Figure 14.6 Panoramic radiograph of the bruxism patient from Figure 14.5 showing the extent of the fractured implant. Also notice multiple fractured teeth, fractured restorations, multiple missing teeth, as well as an acute gonial angle.

Figure 14.7 Panoramic radiograph showing all six maxillary implants being placed at a 30–45° tilt to overcome anatomic restrictions and allow a successful immediate load of the implants.

Figure 14.8 Illustration showing the susceptibility of an internal‐connection implant to hoop stress, which requires the relatively thin walls of the implant to carry the load due to external‐directed (centrifugal) forces.

Figure 14.9 Illustration showing the advantage provided to an internal‐connection implant when the restoration is supported by the implant pillar itself. In this situation, the implant is loaded by internally directed compressive (centripetal) forces.

Figure 14.10 Image showing initial attempt at obtaining a complete and passive seating of a splinted implant‐supported restoration using a silicone disclosing medium.

Figure 14.11 Image of the same restoration as Figure 14.10, after adjustments of internal aspect, and proximal contacts show complete seating as revealed by the silicone disclosing medium.

Figure 14.12 Image of a cast metal–resin mandibular fixed prosthesis showing excessive cantilever. This type of cantilever is detrimental to the prosthetic components but not necessarily detrimental to the osseointegration surface itself.

Figure 14.13 Use of implant‐supported cast gold restorations in a patient with severe bruxism.

Figure 14.14 Image of the same patient from Figure 14.13, at a 10‐year follow‐up showing wear facets and changes in soft tissue but absence of restoration failure.

Figure 14.15 Image showing use of an 8 μm shim stock to confirm occlusal contacts of natural teeth while inserting a posterior implant‐supported restoration.

Figure 14.16 Occlusal view of a patient with severe bruxism being restored with cast gold restorations in the second premolar and molar regions (where forces are significantly higher) and restored with metal–ceramic restorations in the remaining natural teeth.

Figure 14.17 Occlusal view of a patient with severe bruxism who declined cast gold restorations. Metal occlusion can prevent porcelain fracture, which is a common implant occlusion complication. Monolithic zirconia or lithium disilicate restorations are alternatives to a metal occlusal surface.

Figure 14.18 Illustration showing the common reason for fracture of porcelain in an implant‐ supported restoration. The inner metal/ceramic coping lacks normal tooth preparation contours and the final restoration results in the build‐up of excess veneering porcelain that has a high risk of fracture.

Figure 14.19 Illustration showing that custom abutment can more closely reflect the shape of the final restoration and minimize porcelain fracture.

Figure 14.20 By requesting that the dental laboratory technician generate a full contour wax‐up of the final restoration and then manually trimming back by 1.5–2 mm to make space for veneering porcelain of even thickness, the risk for porcelain fracture is minimized.

Figure 14.21 Occlusal view of a maxillary complete‐arch implant‐supported fixed prosthesis fabricated with monolithic zirconia with minimal veneering of porcelain only in the gingival region. Monolithic zirconia is an emerging material that is highly esthetic compared to resin and has promising potential to decrease occlusal material complications.

Figure 14.22 Occlusal view of a mandibular complete‐arch implant‐supported fixed prosthesis in the same patient shown in Figure 14.21, fabricated with monolithic zirconia with minimal veneering of porcelain only in the gingival region.

Figure 14.23 Image showing fabrication of a thin clear vacuum‐formed matrix (screw‐access matrix) for cement‐retained implant restorations. The vacuum‐formed matrix is fabricated directly over the master cast encompassing all remaining teeth.

Figure 14.24 The implant restoration is removed from the master cast and the screw‐access matrix is replaced on the master cast and the screw‐access holes are then drilled, and black lines can be drawn on the buccal and lingual surfaces of the matrix, indicating the direction of the screw channel.

Figure 14.25 Image illustrating the occlusal view of the screw‐access matrix in place with the screw‐access holes marked. This matrix should be preserved in the dentist’s office as a permanent part of the patient’s treatment record.

Figure 14.26 Image illustrating the use of nonwhite colored polytetrafluoroethylene (PTFE) tape to fill the screw‐access channel. Using a colored tape allows easier visibility and access to the screw, if the screw‐access site is drilled through the restoration.

Figure 14.27 Image showing copy abutments of a three‐unit fixed dental prosthesis fabricated from a silicone material. The copy abutments aid in trial cementation and clean‐up of excess cement extruding from the restoration, which allows easier clean‐up in the mouth and minimal residual cement.

Chapter 15

Figure 15.1 Digital prosthodontics platform flow of data.

Figure 15.2 Three‐dimensional surface geometry as described by an STL (stereolithography) file. Black line is original tooth contour, blue line is STL model. Note how the size and density of the triangles will affect the trueness of the model to the original anatomy.

Figure 15.3

(a)

Digital periapical radiograph of potential implant site.

(b)

Three‐dimensionally reconstructed CBCT image.

Figure 15.4 Implant‐planning software showing linear measurements, proximity to vital structures, and 3‐D surface topography.

Figure 15.5

(a)

An example of three‐dimensionally printed casts.

(b)

An example of three‐dimensionally printed maxillary cast with reproduction of maxillary torus.

Figure 15.6

(a)

A digital diagnostic wax‐up for a maxillary right first molar, occlusal view.

(b)

A digital diagnostic wax‐up for a maxillary right first molar, buccal view.

Figure 15.7

(a)

Extraoral 3‐D camera set‐up.

(b)

Extraoral 3‐D facial image.

Figure 15.8 Milled implant surgical guide for a guided surgery protocol.

Figure 15.9

(a)

Example of metallic artifact in CBCT data set.

(b)

Planned implant position for maxillary right first molar site.

(c)

Radiographic try‐in of milled surgical guide from digital implant plan showing angle deviation from original plan. This is most likely due to metallic artifact causing an inaccurate registration of the CBCT data set and the intraoral scan data set.

(d)

Corrected implant position and angulation after manual correction of surgical guide.

Figure 15.10 Long‐term milled CAD/CAM interim crowns for central incisor implants at the time of prosthesis delivery. Surface characterization and staining completed by hand.

Figure 15.11

(a)

Maxillary full‐arch digital diagnostic impression from an intraoral scanner.

(b)

Mandibular full‐arch digital diagnostic impression from an intraoral scanner.

Figure 15.12 Specialized healing abutment with milled patterns to indicate implant depth, rotational timing, platform diameter, and external versus internal connection type.

Figure 15.13

(a)

Various scanbody geometries from different manufacturers.

(b)

Intraoral implant scanbodies for digital impressioning systems. Note the incisal bevel that must be oriented to the facial for proper CAD software registration.

Figure 15.14

(a)

Three‐dimensionally printed implant definitive cast.

(b)

Close‐up of the printed detail of the socket to receive the implant analog.

(c)

Implant analog for milled or printed casts.

(d)

Implant analog inserted into printed cast.

(e)

Verification window in printed casts to confirm complete seating of implant analog and/or abutment.

Figure 15.15 Proper isolation, field control, and contrast medium application for intraoral scanning of implant scanbodies.

Figure 15.16

(a)

A maximum intercuspation position acquired with an intraoral scanner. Instructing the patient to close with even pressure bilaterally is helpful in obtaining an accurate registration.

(b)

Occlusal registration as verified from “underneath”. Even distribution of white “burn through” would be indicative of appropriate occlusal registration. Use of shim stock to verify key occlusal stops is a good practice.

(c)

The unique lingual perspective of the occlusion.

Figure 15.17

(a)

Custom‐milled zirconia abutment from manufacturer blank that has premachined implant interface.

(b)

Custom‐milled monolithic zirconia screw‐retained implant fixed dental prosthesis.

Figure 15.18

(a)

Titanium base for a hybrid abutment.

(b)

Milled custom zirconia crown. Note the milled anti‐rotational features on the intaglio surface.

(c)

Hybrid abutment components assembled and bonded together.

Figure 15.19

(a)

daVinci surgical robot in position for transoral‐robotic assisted radical tonsillectomy (Intuitive Surgical, Inc., Sunnyvale, CA).

(b)

Intraoperative view during radical tonsillectomy for T1 tonsillar cancer.

Figure 15.20

(a)

Example of various sizes and shapes of intraoral scanners.

(b)

Impact of the physical geometry on oral access of intraoral scanners.

Figure 15.21 Overlay of intraoral scans to monitor the volumetric change of a bone graft in a potential implant site.

Figure 15.22

(a)

Incisal edge positional change of natural teeth relative to implant in right central incisor.

(b)

Opening up of mesial contact between implant crown and natural tooth.

Figure 15.23

(a)

Three‐dimensional reconstruction of tumor.

(b)

Proposed mandibular reconstruction with radial forearm free flap graft.

(c)

Cutting guides on radius for mitered cuts.

(d)

Cutting guides on mandible for precise resection.

(e)

Close‐up of guide on mandible indicating shared holes for guide and reconstruction plate, and right mandible cut guide.

Chapter 16

Figure 16.1

(a)

Vibrating line established with indelible marker.

(b)

Denture in place, demonstrating distal limit engaging the movable soft palate beyond the vibrating line.

(c)

Vibrating line visible on intaglio surface of denture.

Figure 16.2 Peripheral seal lacking with short flange in the retrozygomatic region.

Figure 16.3 Tissue conditioner used first to develop the periphery with a higher viscosity powder/liquid ratio and then a very thin wash for the intaglio surface.

Figure 16.4

(a)

High muscle attachment which negatively affects the prognosis of a complete denture.

(b)

Retruded tongue compromising prognosis of complete denture leading to appropriate implant treatment.

Figure 16.5

(a)

Vertical dimension of rest (VDR) recorded with a boley gauge.

(b)

Vertical dimension of occlusion (VDO) registered with less than 1 mm difference between VDR and VDO. This demonstrates insufficient interocclusal distance for a class I patient.

Figure 16.6

(a)

Balanced complete denture wax‐up (centric relation position).

(b)

Balanced complete denture wax‐up (right working excursion).

(c)

Balanced complete denture wax‐up (right balancing excursion).

(d)

Balanced complete denture wax‐up (protrusive excursion).

Figure 16.7

(a)

Articulator mounting with remount record in place.

(b)

Lack of posterior bilateral contacts demonstrated on the articulator but not visualized intraorally because of resilient and like effect (REALEFF) of the soft tissue foundation.

(c)

Equilibrated dentures.

Figure 16.8

(a)

Patient presenting with terminal dentition with a loss of dental landmarks.

(b)

Patient restored with complete denture following facial references to create an authentic appearance.

Figure 16.9 Smile line serving as an envelope for the incisal edges of maxillary anterior teeth.

Figure 16.10

(a)

Fricative /f/ sound aiding the practitioner in assessing the coronoapical position of the maxillary central incisors. The incisal edge should lightly touch the vermillion border of the lower lip.

(b)

Sibilant /s/ sound aiding the practitioner in assessing the horizontal overlap of the anterior teeth. Typically the teeth should be 1 mm apart with the /s/ sound.

Figure 16.11

(a)

Variation in axial inclination but the asymmetries do not disrupt a visual balance.

(b)

Horizontal plane view demonstrating bodily displacement of the teeth from a single arc. Note the facial view does not reveal the stark asymmetries but the teeth will appear more individualized and break up the light in a nonuniform fashion.

(c)

Important differences in contact points to guard againt a “denture look”. The incisal embrasures are distinctive.

(d)

Age‐relevant selective grinding of the incisal edges is important to create a natural appearance.

Chapter 17

Figure 17.1

(a)

Panoramic radiograph showing advanced bone resorption in both jaws with increased pneumatization of the maxillary sinuses and alveolar ridge resorption in the anterior maxilla.

(b, c)

Patient’s profile with and without complete dentures in place with obvious need for facial support by prosthesis flanges.

(d)

Clinical situation of the patient with advanced bone resorption following bilateral maxillary sinus augmentation.

(e)

Intraoral surface scan of the mucosal tissues (iTero, San Jose, California).

(f)

CBCT scan with mucosal contour displayed by using jodoform paste applied onto the prosthesis base.

(g)

Image created with coDiagnostiX‐software superimposing the CBCT data with the iTero‐surface‐scan (black line) and an additional surface scan of the prosthesis (Projektor MPT, Breuckmann GmbH, Meersburg, Germany; red line).

(h)

Prosthetically‐driven implant planning for an implant overdenture with bar retention (black line illustrates mucosal contour, red line indicates prosthesis contour).

(i)

Six implants planned.

(j)

Virtual template designed according to the determined implant positions including blueprint for the sleeves.

(k)

Printed template based on exported iTero data transferred as stl.‐file to a 3D‐Printer (Objet Eden, Stratasys; right).

(l)

Postoperative panoramic radiograph after implant placement, using the template for guided preparation of implant beds.

(m)

Prefabricated round Dolder bar (soldered gold bar).

(n)

IOD with cast framework and clips inserted (Galak, Cendres & Métaux). (Technician: Clemens Gessner, Basel.)

Figure 17.2 Dentate

(a, b)

and edentulous

(c, d)

maxillae (occlusal and lateral views).

Figure 17.3

(a)

Clinical situation of existing denture with adequate tooth position.

(b)

Denture is used to fabricate a resilient cast, which is keyed to visualize the relationship between ideal tooth position and underlying tissues.

(c)

Cast is used to fabricate a surgical template.

(d)

Set‐up made without buccal flange, clearly illustrating that soft tissue support can only be provided by an implant overdenture.

(e)

Clinical situation with six implants placed.

(f)

IOD retained at stud abutments (locators) and an anterior bar (Bredent Vario Soft) with an overcast.

(g, h)

Clinical situation with reduced palatal coverage and buccal flange extension. (Technician: Alwin Schönenberger, Vision Dental Chiasso.)

Figure 17.4

(a, b)

Initial examination in a patient with a short lip line (15 mm measured from subnasal to philtrum in repose) with adequate denture or diagnostic set‐up in place. The full length of a periodontal probe serves as a reference for the average length of maxillary incisors (23.5 mm), which have to fit below the subnasal point, and helps to determine the adequate incisal edge position.

Figure 17.5

(a)

Set‐up keyed to produce a transparent template.

(b)

Template mounted in a surveyor to determine a similar path of insertion and to mill the holes for titanium markers.

(c)

Reformatted CT scan illustrates large discrepancy between ideal tooth position (indicated by titanium markers) and underlying maxillary bone.

(d)

Radiographic template modified for application during implant placement.

(e)

Template try‐in illustrating discrepancy between alveolar ridge and diagnostic tooth position in the horizontal dimension.

(f)

IOD retention with casted gold bar with Bredent Vario soft elements.

(g)

IOD in place.

(h)

Anterior view with buccal flange.

(i)

Matrix exchange in the metal reinforcement.

(j)

Anterior view.

(k)

Side view.

(j)

and

(k)

illustrate adequate soft tissue support.

Figure 17.6

(a)

Patient‘s profile with existing removable prosthesis in place showing excessive upper lip support.

(b)

Anterior view.

(c)

Reformatted CT scan illustrates close proximity between ideal tooth position (indicated by titanium markers) and underlying maxillary bone with limited bone resorption.

(d)

Eight implants provided with abutments for screw‐retained implant‐supported fixed dental prosthesis.

(e)

Modification of the temporary using composite filling material to mold the soft tissues in the pontic area.

(f)

Transfer of the ideal temporary situation using a mounted cast.

(g)

The temporary prosthesis screwed back on the master cast and keyed with silicon.

(h)

Framework try‐in combined with occlusal check using laboratory‐prepared stops.

(i)

Implant fixed dental prosthesis with PFM design (metal–ceramic).

(j)

Convex pontic contour in the area of the central incisors.

(k)

Clinical situation with closure of the screw access holes using a little cotton, white gutta percha, and composite filling material.

(l, m)

Anterior view.

(n)

Periapical radiographs.

Figure 17.7

(a)

Clinical situation with eight implants provided with angulated abutments.

(b)

Screw‐retained implant fixed complete denture.

(c)

Denture designed with acrylic resin and gingiva compartment.

(d)

Anterior view.

(e)

Detailed view at 2‐year follow‐up.

Figure 17.8

(a)

Clinical situation of an individually milled bar with 2° taper.

(b)

IOD with gold overcast.

(c)

Anterior view.

(d)

Periapical radiographs.

Figure 17.9

(a)

Signs of wear of ball abutments on implants with non‐parallel angulation, hyperplasia around posterior tissue‐level implant.

(b)

Wear of individually milled bar with a Bredent element.

(c)

Wear of individually milled bar and an additional Ceka attachment.

Chapter 18

Figure 18.1

(a)

Hourglass morphology of anterior mandibular bone as seen on CBCT.

(b)

Mandibular lingual concavity as seen on CBCT.

Figure 18.2

(a)

U‐shaped arch restored with two solitary anchors which may demonstrate anterior–posterior rotation on incisal biting.

(b)

V‐shaped arch managed with three implants to resist anterior lever arm.

Figure 18.3

(a)

Square‐shaped arch with limited projected anterior–posterior (AP) span for vertically placed implants.

(b)

Limited cantilever extension for implant fixed complete denture due to minimal AP span generated by vertically placed implants and adhering to formula (cantilever = 1.5AP span).

(c)

Radiographic depiction of shortened cantilever IFCD.

(d)

Graphic illustrating the extended occlusal table and reduced cantilever afforded by tilted terminal implants.

(e)

Square arch reconciled by tilted implants.

(f)

Radiographic depiction of All‐on‐4 prosthesis in

(e)

.

Figure 18.4 Cantilever extension implant overdenture anchorage system designed to improve stability with class II patients, improve retention with intransigent gaggers, or/and protect sensitive mucosa over mental foramina region.

Figure 18.5

(a)

Multiple implants placed in edentulous mandible opposing a natural dentition.

(b)

Frontal view of mandibular implant overdenture opposing natural dentition.

(c)

Occlusal view of mandibular implant overdenture opposing natural dentition.

Figure 18.6

(a)

Locator® anchorage system requiring ≥8 mm of interarch space from crest of soft tissue to opposing dentition.

(b)

Dolder bar anchorage system requiring 12 mm of interarch space from crest of soft tissue to opposing dentition.

(c)

Spark‐eroded 2‐degree milled bar anchorage system requiring ≥12 mm of interarch space from crest of soft tissue to opposing dentition.

(d)

Cameo view of suprastructure of milled bar overdenture.

(e)

Implant fixed complete denture requiring ≥12 mm of interarch space from crest of soft tissue to opposing dentition.

(f)

Limited resorption of ridge allowing for a porcelain‐fused‐to‐metal design (implant fixed dental prosthesis). Placement of implants is critical to be congruent with restorative design.

(g)

Porcelain‐fused‐to‐metal implant reconstruction requiring 8–10 mm of interarch space.

Figure 18.7

(a)

Kois Facial Analyzer in place to transfer, three‐dimensionally, the position of the maxillary denture to the articulator.

(b)

Maxillary denture positioned on mounting stand via registration material. The intaglio surface of the denture is filled with laboratory putty and paper clips are engaged in the putty to provide retention for mounting stone.

(c)

The maxillary denture is mounted on the articulator and the mandibular denture is hand articulated to it (given vertical and horizontal records are appropriate). The intaglio surface of the mandibular denture is filled with laboratory putty and reinforced with paper clips in preparation for mounting on the articulator.

(d)

Dentures are removed to reveal mounted resilient casts.

(e)

Vertical measurement determined between occlusal aspect of maxillary denture and mandibular ridge crest.

(f)

Lang Denture Duplicator with alginate, used to create a replica of existing denture or ideal wax‐up for radiographic/surgical template.

(g)

Radiographic/surgical template.

(h)

CBCT scan with software program orienting the implants in three dimensions with radiographic template in place for a two‐implant overdenture design.

(i)

Duplicate dentures with anterior flanges removed.

(j)

Profile of patient with complete dentures in place, demonstrating excessive lip support from anterior flanges.

(k)

Profile of patient with flangeless duplicates of dentures in place demonstrating natural lip contours.

(l)

Preoperative evaluation of orthopantomogram for available bone for implant placement. Need for alveoplasty was dictated by the resilient cast measurement.

(m)

Implant placement after alveoplasty.

(n)

Definitive implant fixed complete dentures in place.

Figure 18.8

(a)

Preoperative orthopantomogram of edentulous maxilla and terminal mandibular dentition.

(b)

CBCT scan displaying potential sites for implants using software program.

(c)

CBCT scan of implant positions using three anterior vertical implants and two tilted terminal implants.

(d)

3‐D rendering of preoperative mandible with two cross pins established for referencing templates.

(e)

Virtual alveoplasty.

(f)

First template keyed to the existing dentition to orient osteotomy for cross pins.

(g)

Second template oriented by cross pins for alveoplasty.

(h)

Third template oriented by cross pins for implant placement.

(i)

Orthopantomogram of implant placement and immediate provisional prosthesis.

(j)

Definitive prostheses.

Figure 18.9

(a)

Two‐implant solitary anchor design (Locator

®

) for overdenture.

(b)

Four‐implant splinted bar design for overdenture.

Figure 18.10 Single symphyseal design (Locator

®

) for overdenture.

Figure 18.11 Two‐implant splinted bar design with distal cantilever extensions.

Figure 18.12 Food impaction disclosed in internal well of the Locator

®

abutment.

Figure 18.13

(a)

Nylon attachment inside metal housing engaging the internal well of Locator

®

abutment.

(b)

Extended‐range nylon attachment inside metal housing not engaging the internal well of Locator

®

abutment.

Figure 18.14

(a)

Melted Adaptol

®